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CC-15-2786 s Certificate of Completion Miami Shores Village 10050 NE 2 Ave, Miami Shores FI, 33138 Tel: 305-795-2204 Fax: 305-756-8972 Building Inspection Department This certificate issued pursuant to the requirements of the Florida Building Code 106.1.2 certifying that at the time of issuance this structure was in compliance with the various ordinances of the jurisdiction regulating building construction or use. For the following: Permit Type COMMERCIAL CONSTRUCTION Bldg. Permit No. CC-1-15-2786 Owner DVS LLC Contractor EARTH BOUND CONSTRUCTION INC Subdivision/Project NONE Date Issued 01/27/2016 Occupancy r Construction Type III-B Load 9 i Square Footage 850 O pepancy B I Description of INTERIOR RENOVATIONS Applicable 2014 FLORIDA BUILDING I Work Code ` +# Location 9533 NE 2 AVE yl Miami Shores FL 33138 � ; ORE isG 1932l .u■ M Building Officials Approval Ismael Naranjo, CBO 1 Not Transferable R�Dp' POST IN A CONSPICUOUS PLACE I i 1 II i r 1 k. • 1" SPECTION RECORD POST ON SITE Permit NO. CC-11-15-2786 `yNoR£s Miami Shores Village -- Permit Type:Commercial Construction ` Ym 10050 N E.2nd Avenue -�- �- Miami Shores,FL 33138-0000 Worts Classification:Alteration Ph - N so one: (305)795-2204 Fax: (305)756-8972 Issue Date: 2/1/2016 t0RIO p' Expires: 0730// 2016 INSPECTION REQUESTS: (305)762-4949 or Log on at https://bldg.miamishoresvillage.com/cap REQUESTS ARE ACCEPTED DURING 8:30AM-3:30PM FOR THE FOLLOWING BUSINESS DAY. Requests must be received by 3 pm for following day inspections. Commercial Construction Parcel #:1132060133910 Owner's Name: Owner's Phone: (305)756-3711 Job Address: 9533 NE 2 Avenue Total Square Feet: 850 Kamm Shores FL 33138-0000 Total Job Valuation: $ 20,000.00 Bond Number: WORK IS ALLOWED MONDAY THROUGH SATURDAY, 7:30AM-6:OOPM.NO WORK IS ALLOWED ON Contractor(s) Phone Primary Contractor SUNDAY OR HOLIDAYS. i EARTH BOUND CONSTRUCTION Its (305)431-2007 Yes BUILDING INSPECTIONS ARE DONE MONDAY THROUGH THURSDAY. ROOFING INSPECTIONS ARE DONE MONDAY THROUGH FRIDAY. NO BUILDING INSPECTIONS DONE ON FRIDAY. NO INSPECTION WILL BE MADE UNLESS THE PERMIT CARD IS DISPLAYED AND HAS BEEN APPROVED. PLANS ARE READILY AVAILABLE. IT IS THE PERMIT APPLICANT'S RESPONSIBILITY TO ENSURE THAT WORK IS ACCESSIBLE AND EXPOSED FOR INSPECTION PURPOSES. NEITHER THE BUILDING OFFICIAL NOR THE CITY SHALL BE LIABLE FOR EXPENSE ENTAILED IN THE REMOVAL OR REPLACEMENT OF ANY MATERIAL REQUIRED TO ALLOW INSPECTION. WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE COMMENCING WORK OR RECORDING YOUR NOTICE OF COMMENCEMENT. INSPECTION RECORD STRUCTURAL INSPECTION DATE INSP INSPECTION DATE INSP INSPECTION DATE INSP Foundation Zoning Final Stemwall ZONING COMMENTS Rough Slab Water Service Columns 1 st Lift 2M Rough Columns 2nd Lift Top Out Tie Beam Fire Sprinklers Truss/Rafters Septic Tank Roof Sheathing Sewer Hook-up_ Bucks j Roof Drains Windows/Doors ELECTRICAL Gas Interior Framing Z 6 INSPECTION DATE INSP LP Tank Insulation Temporary Pole Well Ceiling Grid 30 Day Temporary Lawn Sprinklers Drywall /t1 2 /O (, Pool Bonding Main Drain Firewall Pool Deck Bonding Pool Piping Wire Lath Pool Wet Niche Backflow Preventor Pool Steel Underground Interceptor Pool Deck Footer Ground Catch Basins Final Pool lab Condensate Drains Final Fence Wall Rough HRS Final Screen Enclosure Ceiling Ro Driveway Roug Ip PLUMBING COMMENTS Driveway Base Tele h ne Rou h Tin Cap Telephone Final Roof in Progress TV Rough Mop in Progress TV Final Final Roof Cable Rough Shutters Attachment Cable Final Final Shutters Intercom Rough Rails and Guardrails Intercom Final MECHANICAL ADA com liance J Alarm Rough INSPECTIONDATE INSP Alarm Final Underground Pipe DOCUMENTS Fire Alarm Rough Soil Bearing Cert Fire Alarm Final Rough Soil Treatment Cert Service Work With Floor Elevation SurveyVentilation Rough Reinf Unit Mas Cert ELECTRICAL COMMENTS Hood Rough Insulation Certificate Pressure Test Spot Survey Final Hood Final Survey Final Ventilation Truss Certification Final Pool Heater STRUCTURAL COMMENTS Final Vacuum MECHANICAL COMMENTS 7LSPECTION DATE INSP rinkler arm Miami-Dade County Building Department Page I of 2 II' e-Permitting Search: MIAMI DARE ;ri-. lt:t= car:, Resident Isitof Business Employee MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 02/10/2016 MUNICIPAL NO.2016-017618 FOLIO: 1132060133910 JOB SITE ADDRESS 9533 NE 2 AVE PROPOSED USE OFFICE-PROFESSIONAL BUILDINGS/NEW PARTITIONS LEGAL 1 53 41 6 53 42 MIAMI SHORES SEC 1 AMD PB 10-70 APPLICATION TYPE ALTER INTERIOR 850 SQFT 1 UNITS 1 FLOORS OWNER NAME DVS LLC CONTRACTOR EARTHBOUND CONSTRUCTION INC QUALIFIER RODRIGUEZ-SCHACK ERIC PERMIT TYPE MUNICIPAL BLDG CATEGORIES 0001 MUNICIPAL GENERAL BUILDING DATE: 2/10/2016 PROCESS NUMBER: M2016002010 NEW"AMOUNT PAID 346.68 DERM 1 ASBESTOS REVI 175.00 DERM 1 UP FRONT FEE-80.00 DERM 1 MIN COMM REV(90.00 FIRE 20000 ALTERATIONS& 117.00 FIRE 20000 FIRE UPFRT FE 34.32 FRWK 1 1ST FIRE MING 79.00 UPMU 1 UPFRONT FEE F 25.00 1/8/2016 09:55 BNZWEB1 181601080162 WEBIPAS 346.68 MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 02/10/2016 MUNICIPAL NO.2016-017618 PROCESS NO. M2016002010 FOLIO: 1132060133910 JOB SITE ADDRESS 9533 NE 2 AVE PROPOSED USE OFFICE-PROFESSIONAL BUILDINGS/NEW PARTITIONS REQUIRED INSPECTIONS INIT DATE FIRE 0001 FIRE INSPECTIONS RECOMMENDED 200 FIRE HYDRANTS 208 FIRE TCO INSPECTION 211 PRELIMINARY 209 FIRE FINAL J_T 9 G o MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 02/10/2016 MUNICIPAL NO.2016-017618 PROCESS NO. M2016002010 FOLIO: 1132060133910 JOB SITE ADDRESS 9533 NE 2 AVE PROPOSED USE OFFICE-PROFESSIONAL BUILDINGS/NEW PARTITIONS INSP INSP INSPECTION DISP RESULT INSP TYPE DATE !------------COMMENTS-------------I CODE DATE INIT 209 0/0/0 000 0/0/0 http://egvsys.co.miami-dade.fl.us:1608/W W WSERV/ggvt/BNZA W922.DIA?PROS=M20... 2/10/2016 I Miami-Dade County Building Department Page 2 of 2 MUNICIPAL INSPECTION REQUIREMENTS AND RECORD 02/10/2016 MUNICIPAL NO.2016-017618 PROCESS NO. M2016002010 FOLIO: 1132060133910 JOB SITE ADDRESS 9533 NE 2 AVE PROPOSED USE OFFICE- PROFESSIONAL BUILDINGS/NEW PARTITIONS TO SCHEDULE A FIRE INSPECTION, PLEASE VISIT THE WEB AT WWW.MIAMIDADE.GOV/BUILDING OR WWW.MIAMIDADE.GOV/FIRE. YOU WILL NEED TO PROVIDE YOUR TEN DIGIT MUNICIPAL INSPECTION NUMBER AND INSPECTION TYPE. THE INSPECTION TYPE CAN BE FOUND ON YOUR INSPECTION REQUIREMENTS AND RECORDS CARD. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING AN INSPECTION, SCHEDULING A PRELIMINARY INSPECTION, OR LOAD BANK TEST INSPECTION, PLEASE CALL FIRE PREVENTION AT 786-331-4800. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING A PLAN REVIEW, PLEASE CALL FIRE ENGINEERING AT(786)315-2771. **BE ADVISED THIS IS NOT A PERMIT. PERMIT IS TO BE ISSUED BY YOUR CORRESPONDING MUNICIPAL BUILDING DEPARTMENT. Back to Main Menu BLDG Home Page I BLDG Main Menu I BLDG Permit Menu I BLDG Plans Processing Menu I Inspection Types I Address Format Home I About I Phone Directory I Privacv I Disdaimer E-mail your comments,questions and suggestions to Vebmaster This page was last edited on: February 23,2004 Web Site©2004 Miami-Dade County. All rights reserved. http://egvsys.co.miami-dade.fl.us:1608/WWW SERV/ggvt/BNZAW922.DIA?PROS=M20... 2/10/2016 Inspection Worksheet Miami Shores Village 10050 N.E.2nd Avenue Miami Shores, FL Phone: (305)795-2204 Fax: (305)756-8972 Inspection Number: INSP-252672 Permit Number: CC-11-15-2786 Scheduled Inspection Date: February 11,2016 Permit Type: Commercial Construction Inspector: Rodriguez,Jorge Inspection Type: Final Owner: , Work Classification: Alteration Job Address:9533 NE 2 Avenue Miami Shores, FL 33138-0000 Phone Number (305)756-3711 Parcel Number 1132060133910 Project <NONE> Contractor: EARTH BOUND CONSTRUCTION INC Phone: (305)431-2007 Building Department Comments REMOVE& REPLACE DRYWALL PARTITION Infractio Passed Comments INSPECTOR COMMENTS False TORO FAMILIY CHIROPRACTIC Inspector Comments Passed 1 Failed Correction ❑ Needed Re-Inspection ❑ Fee No Additional Inspections can be scheduled until re-inspection fee is paid February 10,2016 For Inspections please call: (305)762.4949 Page 38 of 38 Miami Shores Village T Building Department No 10050 N.E.2nd Avenue,Miami Shores,Florida 33138 BY_ Tel:(305)795-2204 Fax:(305)756-8972 INSPECTION LINE PHONE NUMBER:(305)762-4949 S+41 FBC 201q BUILDING Master Permit No. 86 PERMIT APPLICATION Sub Permit No. BUILDING ❑ ELECTRIC ❑ ROOFING ❑ REVISION ❑ EXTENSION ❑RENEWAL ❑PLUMBING ❑ MECHANICAL ❑PUBLIC WORKS ❑ CHANGE OF ❑ CANCELLATION ❑ SHOP CONTRACTOR DRAWINGS JOB ADDRESS: 533 N E, Z Ave City: Miami Shores County: Miami Dade Zia: 93139 Folio/Parcel#: 11 - 11067 Oil (0 Is the Building Historically Designated:Yes NO Occupancy Type: Load: Construction Type: Flood Zone:,/� BFE: FFE: OWNER:Name(Fee Simple Titleholder): !c/lb A � �;11ag e Sq l.c4r� ✓''Phone#; ?9� y 23, -?S Y Address: AA2 01 til E City: Jul►4m i 86tes State: PL Zip: 33)-39 Tenant/Lessee Name: t"I-.A u.e I —r>9D Phone#:20 5' a 63 b T !2 Email: I 1 o b�C4 m' G a "c- 0 M CONTRACTOR:Company Name: Phone#: 1- 0� Address: -� 'f City: State: Zip: 243 Qualifier N e: Phone#: OF State Certification or Registration#: ,/ —dr-!q!2. _Certificate of Competency#: DESIGNER:Architect/Engineer: OrQP_ khAc't4 Phone#: Address: City: State: Zip: Value of Work for this Permit:$ 26 K Square/Linear Footage of Work: Type of Work: ❑ Addition DS Alteration New ❑ Repair/ eplaceDemolition F Description of Work: �• �. P,0 if A J>It Ji I%�d LC1 I Specify color of color thru tile: Submittol, ee$ Permit Fee$ 60,6D CCF$ L a6� o� a 3xs`c a Radon Fee$ o® DBPR$ q" Notary$ �® "- Technology Fee$ j�o1� Training/Education Fee$ 400 Double Fee$ D Structural Reviews$ I Bond$ TOTAL FEE NOW DUE$ (Revised02/24/2014) 5 Bonding Company's Name(if applicable) Bonding Company's Address City State Zip Mortgage Lender's Name(if applicable) APZA Mortgage Lender's Address City State Zip Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this jurisdiction. I understand that a separate permit must be secured for ELECTRIC, PLUMBING, SIGNS, POOLS, FURNACES,BOILERS,HEATERS,TANKS,AIR CONDITIONERS,ETC..... OWNER'S AFFIDAVIT: I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable laws regulating construction and zoning. "WARNING TO OWNER: YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT." Notice to Applicant: As a condition to the issuance of a building permit with an estimated value exceeding$2500, the applicant must promise in good faith that a copy of the notice of commencement and construction lien law brochure will be delivered to the person whose property is subject to attachment. Also,a certified copy of the recorded notice of commencement must be posted at the job site for the first inspe rc t occurs se v ays after the building permit is issued. In the absence of such posted notice, the inspection ' not roved an einspection will be charged. Signat a Signature N or AG CONTRACTOR The foreg ' g instr ent was acknowledged before me this The foregoing instrument was acknowledged before me this H day of 20 ,by day of eO C - ,20 by �12P� t T2c ,who is personally known to tG2 C who is personally ki;iqwn to me or who has producedas me or who has produced [ as identification and who did take an oath. identification and who did take an oath. NOTARY PUBLIC: NOTARY PUBLIC: Sign: Z rt- Sign• Print: F*94 b Seal: Seal: Notary Public State of Florida Y P i JIM D.PAMPLIN Joanne M FelFeliciano• • Notary Public-State of Florida Exphes 0111112/X18 0A2783 s•s cr My Comm.Expires Jan 13,2017 �� *xsee***s**a**as** ir� ea*+EbD)fi1tFF�9itlRi�$9P`�"x aa�rxa***eae*ee a *axwewxwe*seee*aswx*a+xeee**arewwx*eea APPROVED BY Plans Examiner Zoning Structural Review Clerk (Revisedo2/24/2014) Property Search Application - Miami-Dade County Page 1 of 1 OFFICF OF i "It" PROWERTly APPRAISER Summary Report Generated On: 11/2/2015 Property Information ' " 4 Folio: 11-3206-013-3910 _- r. Property Address: 9537 NE 2 AVE Miami Shores,FL 33138-2704 E Owner DVS LLC 1 201 NE 95 ST Mailing Address S" MIAMI SHORES, FL 33138 USA N� Primary Zone 6400 COMMERCIAL-CENTRAL , Primary Land Use 1111 STORE: RETAIL OUTLET r Beds I Baths/Half 0/0/0 r � Floors 1 f Living Units 0 Actual Area Sq.Ft i Living Area Sq.Ft 20fi f'Pho Adjusted Area 5,116 Sq.Ft Awl _................ Lot Size 13,000 Sq.Ft Taxable Value Information Year Built �� 1926 2015 2014 2013 Assessment Information County Exemption Value $0 $0 $0 Year 20152014 2013 Taxable Value $627,000 $570,000 $518,671 Land Value $286,000 $286,000 $286,000 School Board Building Value $394,000 $284,000 $222,403 Exemption Value $0 $0 $0 XF Value $0 $0 $10,268 Taxable Value $680,000 $570,000 $518,671 Market Value $680,000 $570,000 $518,671 City Assessed Value $627,000 $570,000 $518,671 Exemption Value $0 $0 $0 Benefits InformationTaxable Value $627,000 $570,000 $518,671 .......................................................................... . Benefit Type 2015 2014 2013 Regional Non-Homestead Cap Assessment Reduction $53,000 Exemption Value $0 $0 $0 Note:Not all benefits are applicable to all Taxable Values(i.e.County, Taxable Value $627,000 $570,000 $518,671 School Board,City,Regional). Sales Information Short Legal Description Previous OR Book- Sale Price PageQualification Description 1 5341 6 53 42 _._...................._.. MIAMI SHORES SEC 1 AMD PB 10-70 12/23/2010 $1,600,000 27542- Qual on DOS,multi-parcel sale _..4._.._ 4900 LOTS 10&11 BLK 29 08/06/2010 $100 27394- Corrective,tax or QCD;min LOT SIZE 13000 SQUARE FEET 3799 consideration OR 16249-1695 0294 5 22525- Sales which are disqualified as a result 07/01/2004 $0 4025 of examination of the deed .............. 02/01/1994 $0 16249- Sales which are disqualified as a result 1695 of examination of the deed The Office of the Property Appraiser is continually editing and updating the tax roll.This website may not reflect the most current information on record.The Property Appraiser and Miami-Dade County assumes no liability,see full disclaimer and User Agreement at hftp://www.miamidade.gov/info/disclaimer.asp Version: http://www.miamidade.gov/propertysearch/ 11/2/2015 Detail by Entity Name Page 1 of 2 Detail Entity Name Florida Limited Liability Company DVS, LLC Filing Information Document Number L10000129579 FEI/EIN Number 80-0670481 Date Filed 12/20/2010 Effective Date 12/17/2010 State FL Status ACTIVE Principal Address 201 N.E. 95th Street MIAMI SHORES, FL 33138 Changed: 04/14/2013 Mailing Address 201 N.E. 95th Street MIAMI SHORES, FL 33138 Changed: 04/14/2013 Registered Agent Name &Address CACCAMISE, THERESA 201 N.E. 95th Street MIAMI SHORES, FL 33138 Name Changed: 04/14/2013 Address Changed: 04/14/2013 Authorized Person(s) Detail Name & Address Title MGRM CACCAMISE, THERESA 201 N.E. 95th Street MIAMI SHORES, FL 33138 Title MGRM http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail?inquirytype=Entity... 11/2/2015 Detail by Entity Name Page 2 of 2 CACCAMISE, RICHARD 201 N.E. 95th Street MIAMI SHORES, FL 33138 Annual Reports Report Year Filed Date 2013 04/14/2013 2014 01113/2014 2015 03/12/2015 Document Images 03/12/2015--ANNUAL REPORT View image in PDF format 01/13/2014—ANNUAL REPORT View image in PDF format 04/14/2013 ANNUAL REPORT F—View image in PDF—format--] 03/20/2012 ANNUAL REPORT View image in PDF format 05/16/2011 --ANNUAL REPORT View' image in PDF—format ---] 12/20/2010— Florida Limited Liability View image in PDF format:71 couricts v and Privacy Policies State of Florida,Department of State http://search.sunbiz.org/Inquiry/Corporatio�Search/SearcbResultDetail?inquirMpe=Entity... 11/2/2015 1 r STATE OF FLORIDA ' DEPARTMENT OF BUST ,ESS AND PROFESSIONAL REGULATION t CONSTRUCTI N INDUSTRY LICENSING BOARD CGC1512496 i~ The GENERAL CONTRACTOR Named below IS CERTIFIED Under theprovisions of Chapter 489 FS. Expiration date: AUG 31,2016 RODRIGUF_Z-SCIACK, ERIC 'h EARTHBOUND CONSTR INC a . 611'S.W.23RD RD. MIAMI- F1=33129-- ISSUED: 09/02!2014 DISPLA` AS REQUIRED BY LAW SEQ# L1409020001759 tB21� Local Business Tax receipt Miami-Dade County, State of Florida �LB.T THIS IS NOTA BILL - DO NM PAY 59731:98, OUSOHM NA%MWMC^MM eBc�at r NQ- EXPIRES EARTH BOUND CON"'=ON'K,r 10101m SEPTEMBER.30, 2416 611 SW 23 PD 62312" Mug be ctl0Iayad at place of budrAm MIAMI FL 33129 Pumuartt to County Coda Chapter SA-Art.9&10 OWN1:R SBC. F BUSINESS EARTH SOUND CANSTRUCnW INC 196 GE14ERAL13UMNGCOWMCTOR By ME workers) CGC751 TAX COLLECTOR $85.00 08/04/2015 CHECK21-15-111209 ThIsLowtBusims3laxReewptodycmmnn. of the Local BusImm Tax.The Remptism a lweam paRwtora s todoh awo*w%aay8ormanmtel or The RECBPT N0.abom umd be oa aR Iai VW des– C�SW&1 m foraBre lidmmmdoa, ISTATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES IDIVISION OF WORKERS'COMPENSATION CONSTRUCTION INDUSTRY EXEMPTION oeata=*MOFa.acnoxTOeaaxea•rFm=RARmA WORM—COMPMA7MLAW Wo"W DA :QI s MOL47MN OAtB Sn91IM7 aaReo�r ROtxtla�llSEh'SCNACK MW FEN: SWUM BWINESS NAM AND ADDRESS: . I EARTH BOUND"TRUCTM INC . 811 SIN 23RD ROAD IRVAN FL 33128 SCOPES OF BUSINE OR TRA Qf ' "90 10P27/15 CERTIFICATE OF LIABILITY INSURANCE DATE`'"27/15 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WANED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Neu of such endorsement(s). PRODUCER CONTACT Sunset Insurance Corp PHONE . (305)441-9278 FAX C o (305)441-92$2 106 Madeh AveL sunseUnsuramwflfl@gmail.com Corm Gables,FL 33134 INSU S AFFORDING COVERAGE NAICS Phone ( 661-2377 FaX 1-9282 INSURER A: ESSEX INSURANCE COMPANY INSURED INSURER B: Earth Bound Construction INSURER C: 611 SW 23 Rd INSURER D: MIAMI,FL 33129- (305)431-2007 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSSR ADDL SUBRPOLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER M MID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 ® COMMERCIAL GENERAL LIABILITY PRREMIISES�nce $ 100,000.00 A ❑ ❑ CLAIMS-MADE ® OCCUR 3EAS233 10/01/2015 10/01/2016 MED EXP(Any one person $ 5,000.00 ❑ PERSONAL&ADV INJURY $ 1,000,000.00 ❑ GENERAL AGGREGATE $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ 1,000,000.00 ❑ POLICY ❑ PN- ❑ LOC DEDUCTIBLE $ 1,000.00 AUTOMOBILE LIABILITYa SINGLE LIMIT ❑ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDU ❑ AUTOS ❑ AUTOS LED BODILY INJURY(Per acdderrg $ ❑ HIRED AUTOS ❑ AUTOS P OP= E $ ❑ $ ❑ UMBRELLA LIAR ❑OCCUR EACH OCCURRENCE $ ❑ EXCESS LIAB ❑CLAIMS-MADE AGGREGATE $ ❑ DED 0 RETENTION$ $ WORKERS COMPENSATIONWC TATU- LIMITS OTH- f AND EMPLOYERS'LL4 1LITY Y 1 N OYER ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? N I A (Mandatory in NH) El E.L.DISEASE-EA EMPLOYE $ W desoribe under DESCRIPTION OF OPERATIONS belay E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) LICENSE NUMBER:CGC:1512496 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE VE DESCRIBED POLICIES BE CANCELLED BEFORE MIAMI SHORES VILLAGE THE EXPIRATION F,NOTICE WILL BE DELIVERED IN BUILDING DEPARTMENT ACCORDANCE TH TH PROVISIONS. 10050 N.E.2ND AVE AUTHORIZED REP ESE7 MIAMI SHORES,FL 33138 MABEL GAR m 8 201 C CORPORATION. All rights reserved. ACORD 25(2010105)QF The and logo are regidered marks of ACORD General Contractors "Built to stay» CGC 1512496 October 29,2015 State of Florida Miami-Dade County Before me this dateonall appeared !1 — P� Y pPeaz' � who,being duly sworn,deposes and says: That he will a on y erson employe by Earth Bound Construction Inc.who shall be working on the Toro Chiroprac 'c ject to ed N.E.2nd Avenue in Miami Shores,Florida 33138 Eric Rodriguez-Scha Sworn to(or affirmed)and subscribed before me this Je day of ,2015 7 A bytDaC, QI Cxu "S;U44 . — . personally known or produced identification/type of identification, `FL 1 V ul t.N Print,Type or SIINDWarne of Notary °oaf Notary Pudic State of Florida Sindia Alvarez �o< My Commission FF 156750 opgd" Expires 0910312018 611 S W 23rd. Road • Miami, Florida 33129• Phone/Fax:305-854-1144 �.�,� Miami Building Department toR>i 10050 N.E.2nd Avenue Miami Shores, Florida 33138 Tel: (305)795.2204 Fax: (305) 756.8972 Notice to Owner — Workers' Compensation Insurance Exemption Florida Law requires Workers' Compensation insurance coverage under Chapter 440 of the Florida Statutes. Fla. Stat. § 440.05 allows corporate officers in the construction industry to exempt themselves from this requirement for any construction project prior to obtaining a building permit. Pursuant to the Florida Division of Workers'Compensation Employer Facts Brochure: An employer in the construction industry who employs one or more part-time or full-time employees,including the owner,must obtain workers' compensation coverage. Corporate officers or members of a limited liability company (LLC) in the construction industry may elect to be exempt if: 1. The officer owns at least 10 percent of the stock of the corporation,or in the case of an LLC,a statement attesting to the minimum 10 percent ownership; 2. The officer is listed as an officer of the corporation in the records of the Florida Department of State,Division of Corporations;and 3. The corporation is registered and listed as active with the Florida Department of State,Division of Corporations. No more than three corporate officers per corporation or limited liability company members are allowed to be exempt. Construction exemptions are valid for a period of two years or until a voluntary revocation is filed or the exemption is revoked by the Division. Your contractor is requesting a permit under this workers' compensation exemption and has acknowledge that he or she will not use day labor,part-time employees or subcontractors for your project.The contractor has provided an affidavit stating that he or she will be the only person allowed to work on your project.In these circumstances,Miami Shores Village does not require verification of workers'compensation insurance coverage from the contractor's company for day labor,part-time employees or subcontractors. BY SIGNING BELOW YOU ACKNOWLEDGE THAT YOU HAVE READ THIS NOTICE AND UNDERSTAND ITS CONTENTS. Signa f 011 St4-f Flonda County of Miami-Dade The foregoing was acknowledge before me this Li day of " ,20/. By 77% iL_ �"c cL,wc: �tl�t,CffM w)�p kno to me or has produced as identification. 4 ww" No LNRABWW8UWkTf' ^.f_S;Se ftI iii: * * My COMMISSM#FF 05M ��a S AL: EXPIRES:Segember 8,2017 �'9�'oFv�o�`°e BdThtuBudgetNoteryServk�s 1